COMMENTARY

Keep an Eye Out For Ocular Syphilis

Tom Peterman, MD, MSc; Kimberly Workowski, MD

Disclosures

February 08, 2016

Editorial Collaboration

Medscape &

An Increase in Cases

The Centers for Disease Control and Prevention (CDC) is seeing an increase in reports of ocular syphilis, and this diagnosis should be on every clinician's radar. Ocular syphilis is a clinical manifestation that can occur at any stage of syphilis, including primary and secondary syphilis. Ocular syphilis can involve almost any eye structure, but posterior uveitis and panuveitis are the most common. Additional manifestations may include anterior uveitis, optic neuropathy, and retinal vasculitis. Ocular syphilis is particularly concerning because it can lead to serious vision problems.[1]

A recent Morbidity and Mortality Weekly Report[2] described 12 cases of ocular syphilis reported between December 2014 and March 2015 in San Francisco and Seattle. In addition to these cases, CDC has received reports of more than 200 cases from 20 states over the past 2 years. The majority of cases have been among gay, bisexual, and other men who have sex with men (MSM) with HIV infection, but many cases have occurred among heterosexual men and women without HIV infection. Several of the cases have resulted in significant sequelae, including blindness.[1]

What Can You Do?

Knowing about ocular syphilis is a first critical step in promptly identifying, reporting, and treating any cases. CDC is calling on you—not just traditional providers of sexually transmitted disease services but all clinicians—to take the following steps to curtail the negative consequences associated with ocular syphilis and protect the health of your patients:

  • Screen for visual complaints in any patient diagnosed with syphilis and conversely screen for syphilis in any at-risk patient with visual symptoms (eg, MSM, persons with HIV infection, or others with risk factors such as multiple or anonymous partners).

  • Ensure an immediate ophthalmologic evaluation for patients with syphilis and ocular complaints.

  • Perform a careful neurologic exam and cerebrospinal fluid (CSF) examination in patients with ocular syphilis.

  • Manage ocular syphilis according to treatment recommendations for neurosyphilis:

    • Aqueous crystalline penicillin G intravenously or procaine penicillin intramuscularly (IM) with probenecid for 10-14 days;

    • Benzathine penicillin (2.4 million units IM once per week for up to 3 weeks) can be considered for cases staged as late-latent or unknown duration, after completion of neurosyphilis treatment regimens).[3]

  • Ensure that patients who have early syphilis without ocular symptoms receive a careful neurologic exam including all cranial nerves.

  • If your patient is diagnosed with syphilis, test for HIV if status is unknown or if previously HIV-negative.

  • New cases of ocular syphilis should be reported to your local or state health department and to CDC.

  • Molecular typing (pre-antibiotic samples of whole blood, primary lesions, moist secondary lesions, CSF, or ocular fluid) is part of CDC's continued assessment of this evolving situation.

If you need advice from CDC on the clinical management of ocular syphilis, contact Dr Kimberly Workowski at 404-639-1898 or kgw2@cdc.gov. If you are planning on collecting ocular fluid or CSF and need assistance with shipment of clinical samples for molecular typing, please contact Dr Allan Pillay at 404-639-2140 or ajp7@cdc.gov.

Web Resources

Clinical Advisory: Ocular Syphilis in the United States

Notes from the Field: A Cluster of Ocular Syphilis Cases — Seattle, Washington, and San Francisco, California, 2014–2015 . MMWR Morb Mortal Wkly Rep. 2015;64;1150-1151.

2015 STD Treatment Guidelines (including wall charts, pocket guides and a free, downloadable app)

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